A Victorian Coroner investigating the crushing death of a worker has recently warned employers to avoid over-reliance on administrative measures – such as training and safe work instructions – as a primary means of risk control.

The role of the Coroners’ Court in Workplace Deaths

In Victoria, Coroners have the power to investigate deaths in certain instances, including where they occurred at a workplace. Where it is deemed appropriate, a Coroner may also conduct an inquest  to uncover the circumstances surrounding the death. This power may be initiated independently of other investigations, such as those undertaken by a regulator (for example, the VWA and VicRoads).

The Coroner’s findings are aimed at determining the facts relating to the cause of death with a view to making recommendations or observations that may relate to public safety. This could include recommending to the Director of Public Prosecutions or any other agency consider whether any person should be prosecuted.

In this case, the Court heard that, at  the time of his death, the deceased  had been employed as a road broom operator and was considered highly experienced at this task. Whilst working on a highway duplication site he because crushed between the rear of his truck and a hydraulic broom attachment.

It was found that the man had entered a “crush zone” while working alone. The attachment to his truck had not stowed correctly and was energised unexpectedly when he was trying to adjust the device manually.  The device was normally operated using a joystick inside the cabin.

The device manufacturer had provided warning and a risk assessment about the potential crush zones and the principal contractor involved had provided induction, policies and safe operating work instructions. A risk assessment had not, however, been conducted following the installation of the device, even after the worker had reported occasional malfunctioning of the device.

Ultimately, the risk control measure for the potential crush zone relied largely on worker compliance, training and auditing – each low on the hierarchy of risk controls. The Coroner found that warning signs placed on the machinery and documents that warned of the crush zone were not effective controls, particularly considering that the worker was working alone.

Critically, her Honour noted that:

Any competent, diligent worker may incidentally deviate from set operating procedures, particularly where a fault may arise with machinery or equipment. No person is immune from errors in judgment.

The Coroner also noted that the incident was foreseeable and could have been detected by a properly conducted risk assessment and recommended that the manufacturer also take heed of the incident when installing such devices in the future.

Key learnings

The Coroner’s observations reinforce important principles about the manner in which a duty holder must assess and implement risk controls in the workplace. All Australian safety regulators provide extensive information on how to apply the hierarchy of risk controls in a wide range of settings. In a number of high-risk areas, the hierarchy has also been modified to create a prescribed approach to its application – such as with noise, asbestos management and certain types of plant.

A decision from the Coroners’ Court that touches on workplace safety can be a valuable source of personal and industry knowledge on how to discharge safety duties. Inquests and investigations adopt a distinct approach to reviewing untimely deaths and the findings tend to be far more detailed than what is available in prosecution decisions.

Regular review of key Coronial decisions may be one way that you can improve your knowledge and your organisation’s approach to safety management, particularly where an investigation relates to your industry.

Coronial findings are usually publically available on Coroners’ Court websites. Prudent employers should periodically review Coronial written findings to update their safety knowledge, particularly if the findings affect your industry or a specific aspect of it.